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Medical Student Perspectives: Is the Physical Exam Dying?

Medical Student Perspectives: Is the Physical Exam Dying?

The future of the physical exam has come into question again in
both the scientific journals and the popular press. For the last
decade or longer, the debate has raged over the value of the annual
physical exam. A study by the Agency for Healthcare Research and
Quality (AHRQ)1, which began in 1989 and was published
in 2006, is commonly cited by opponents of the annual physical.
This systematic review found little evidence that the annual
physical exam improved clinical outcomes. Many saw this report as a
clash of evidence-based medicine and the art of medicine because it
seemed to call into question an age age-old practice.
Interestingly, a New York Times article in 2003 reported
that physicians who helped perform the study continued to offer
annual physical exams because of the ritual of the doctor-patient
relationship2. The most recent news is being made by
physicians who have chosen to stand up and fight for the value of
the physical exam in medical education. As medical students who
plan to go into Internal Medicine, a field where the physical exam
is still used most often, it is up to us to decide if we believe
the physical exam is dying; and if so, should it be
resurrected?

A National Public Radio (NPR) article in September 2010 entitled
"The Fading Art of the Physical Exam"3 highlights the
opinions of Stanford Medical School Professor Abraham Verghese, MD,
MACP, and others who see physical exam skills fading in the face of
new diagnostic technology and electronic medical records. Verghese
is better known as the author of My Own Country and
The Tennis Partner among other books, but he has also been
a prolific and ardent advocate of the physical exam. For example,
his article in the British Medical Journal extols the
benefits of the physical exam and outlines 25 exam skills that
Stanford Internal Medicine residents are expected to master through
their training4. The NPR article reports that Verghese is not only
convinced that the physical exam picks up some potentially missed
diagnoses but that it also offers a healing touch. He may be right
on both accounts. A study published by Reilly, et. al. in The
Lancet in 2003 found that out of 100 patients in a single
hospital, 26 had pivotal physical findings and 7 had physical
findings of disease that would not have been picked up by other
modalities5. The intrinsic benefit of the physical exam
derived through physician-patient contact has been much more
difficult to quantify, but several articles have cited the power of
touch in the physician-patient relationship, including the August
2010 New York Times6 piece written by Dr.
Danielle Ofri, MD, FACP.

Critics of the importance of the physical exam have spoken
against its diagnostic accuracy in comparison to other diagnostic
technology. Indeed, many of the "gold standards" for diagnosis
involve radiologic imaging or laboratory testing. Many doctors who
use the physical exam might still order laboratory tests or imaging
when they expect to find nothing, "just in case". Technologic
advances may indeed have sharpened physicians' diagnostic accuracy
and efficiency, but perhaps the physical exam need not be discarded
by this scientific evidence. Some scholars have explored how the
process can instead be refined using the principles of
evidence-based medicine. Steven McGee, MD, FACP, is the author of
Evidence-based Physical Diagnosis, and his work has been
to study the efficacy of traditional physical exam maneuvers to
predict disease7. His book is dedicated to quantifying
the predictive accuracy of different techniques in terms of the
likelihood ratio (LR). By using physical exam maneuvers that have a
high or low LR, doctors can significantly change the post-test
probability of the presence or absence of a disease. If a physical
exam test has an LR close to 1, it is unlikely to affect the
pre-test suspicion, and the physician can increase his or her
diagnostic efficiency and accuracy by excluding it. The use of the
evidence-based physical exam can also make physicians more
confident in their assessment of the need for further testing.
Another great resource for the predictive value of disease-specific
exam maneuvers is JAMA's The Rational Clinical
Examination8.

So as future Internists, what do you think about the value of
the physical exam? Is molecular medicine outpacing the need for
exam skills? Is the physical exam an innate and irreplaceable part
of being a doctor? Should we spend more time training in physical
diagnosis beyond the first part of medical school? Our answers to
these questions will determine not only the way we practice
medicine but the future of the physical exam as well.

Justin Taylor
Council of Student Members Representative, Midwestern Region
University of New Mexico School of Medicine, 2011
E-mail:
jutaylor@salud.unm.edu